Debates - Canadian Family Physician

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Should residents be allowed to moonlight? NO. Sarkis Meterissian MD MSc FRCS FACS. Cet article se trouve aussi en français à la page 1522. Dr Meterissian's ...

Debates Rebuttal: Toil and trouble? Should residents be allowed to moonlight? NO

YES Sarita Verma

Sarkis Meterissian



r Meterissian’s arguments are based on conjecture rather than evidence and come across as paternalistic.

Moonlighting is incompatible with residents’ work schedules.  Rarely are moonlighting opportunities not regulated in Canada. In almost all moonlighting programs, the added work hours must be approved and monitored closely. In the United States, internal moonlighting hours are counted toward the 80-hour weekly limit on duty hours—as recommended in the Accreditation Council for Graduate Medical Education guidelines. Moonlighting is not educational.  Studies show residents report that moonlighting enhances residency performance and is a positive educational experience.1 Moonlighting does not offer sufficient financial benefits to warrant the extra work.  Increased earnings ease the burden of residents’ loans and debts, greatly reduce stress, and improve lifestyle. Residents with families report that the added money does reduce their debts.2 Moonlighting produces extreme fatigue, which inhibits learning.  The independence of moonlighting promotes professional growth, allowing residents to experience real-world clinical practice and to test future practice sites. Issues of duty hours and wellness should not be lumped in with the issue of other work when residents are off duty. Currently, residents in most provinces can provide patient care and medical services under various forms of restricted registration. Residents’ use of free time is their own concern and, as long as they fulfil their educational and training responsibilities, should not be interfered with.  Dr Verma is a Professor in the Department of Family Medicine, Deputy Dean of the Faculty of Medicine, and Vice Dean of Postgraduate Medical Education at the University of Toronto in Ontario. Competing interests None declared



r Verma argues that moonlighting fills a void in medical services produced by system changes. Are residents supposed to moonlight because of physician shortages or for its inherent educational value? Dr Verma states that moonlighting residents can demonstrate their competence “under supervision.” This is untrue: moonlighting residents are almost always unsupervised. How can they refine their clinical skills without feedback? Dr Verma agrees that moonlighting contravenes resident collective agreements but seems to think that by making it “legal” she can “impose restrictions on the activity.” If she is such a passionate proponent of moonlighting, why does she want to restrict it? Dr Verma assumes that residents can “decide for themselves what is appropriate.” Clearly they cannot, if moonlighting might need to be restricted “if it interferes with educational performance.” The paper that she quotes1 as evidence for the educational value of moonlighting found that most moonlighting residents violated the Accreditation Council for Graduate Medical Education work restriction and that residents with higher student debt were more likely to moonlight. So clearly there is a conflict of interest: residents moonlight for the monetary gain not the educational value.1 In the end we should listen to our residents: 84.8% of emergency medicine residency applicants agreed that unsupervised care by residents carried a higher risk of adverse patient outcomes.2 If asked to assume the patient role, only 22.7% of senior medical residents would allow another resident to treat them for a serious illness or injury.3 Clearly, moonlighting has many disadvantages and one huge addictive attraction: increased income. If allowed, moonlighting will be abused and not only will the education of our residents suffer, but also the care of our patients.  Dr Meterissian is Associate Professor of Surgery and Oncology and Associate Dean of Postgraduate Medical Education at McGill University in Montreal, Que. Competing interests None declared References


1. Li J, Tabor R, Martinez M. Survey of moonlighting practices and work requirements of emergency medicine residents. Am J Emerg Med 2000;18(2):147-51. 2. Glaspy JN, Ma OJ, Steele MT, Hall J. Survey of emergency medicine resident data status and financial planning preparedness. Acad Emerg Med 2005;12(1):52-6.

Cet article se trouve aussi en français à la page 1522.

1. Li J, Tabor R, Martinez M. Survey of moonlighting practices and work requirements of emergency medicine residents. Am J Emerg Med 2000;18(2):147-51. 2. Kazzi AA, Rangdorf MI, Brillman J, Handly N, Munden S. Emergency medicine residency applicant educational debt: relationship with attitude toward training and moonlighting. Acad Emerg Med 2000;7(12):1399-407. 3. Larkin GL, Kantor N, Zielinski JJ. Doing unto others? Emergency medicine residents’ willingness to be treated by moonlighting residents and nonphysician clinicians in the emergency department. Acad Emerg Med 2001;8(9):886-92.

These rebuttals are responses from the authors of the debates in the October issue (Can Fam Physician 2008;54:1366-9). See

Vol 54:  november • novembre 2008  Canadian Family Physician • Le Médecin de famille canadien